Permit City of Tigard • COMMUNITY DEVELOPMENT DEPARTM'CEIVED
11 ---,f .
Re quest for Permit Action JAN 2 G 2016
l •; ,,, 1-, 13125 SW Hall Blvd. •Tigard,Oregon 97223 • 503-718-2439 • C . - Hp
TO: CITY OF TIGARI) V rill
I r •
Building Division
13125 SW Flail Blvd.,Tigard,OR 97223 3/2// •
Phone: 503-718-2439 Fax: 503-598-1960 TigatdBuildingPermits@tigard-or.gov
FROM: ❑ Owner ❑ Applicant contractor ❑ City Staff
Check(1)one
REFUND OR Narnc:
INVOICE TO: (Business or Individual) -e.-CA/1
Mailing Address: V 0 . /I Fg
City/State/Zip: YJ C, 'f L1 i 11 1 DK )D k,
Phone No.: () — 0 T s
•
PLEASE TAKE ACTION FOR THE ITEM(S) CHECKED (✓):
j (ICANCEL/VOID PERMIT APPLICATION.
❑ REFUND PERMIT FEES (attach copy of original receipt and provide explanation below).
❑ INVOICE FOR FEES DUE (attach case fee schedule and provide explanation below).
❑ REMOVE/REPLACE CONTRACTORp� ONPERMIT (do not cancel peanut).
Permit#: Iv b G-C:2 0 I, 6 .— 0 0,0p .._.. J q
Site Address or Parcel#: LV1 5 ¶v0 117J • 1 ,, t ,1 22-3
Project Name: 5w11-41
Subdivision Name: LA4Q- LeAr0 _ae.. Lot#:
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LA,NATION: 0.4.4 -i-�Nvyte47' .._AL.L., - vl S . Gt:' 12:7-''1
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Signature: (i Avvii,v [41 Date: ( ~ 2-S 1 i
Print Name: A0.4/"J.vV\ 4M11 .e/k "'
Refund Policy
1_ The city's Community Development Director,Building Official or City Engineer may authorize the refund of
• Any fee which was erroneously paid or collected.
• Not more than 80%of the application or plan review fee when an application is withdrawn or canceled before review effort
has been expended.
• Not more than 80%of the application or permit fee for issued permits prior to any inspection requests.
2_ All refunds will be returned to the original payer in the form of a check via US postal serv, -Fa
3. Please allow 3-4 weeks for processing refund requests. 90. ry 7.2. " _ /P ()-°
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Pe.6V Po./G
FUR 01-1.1(11_, 1_.SC ()NT V
Route to Sys Admin: Date I AG /4# B. 7 Route to Records: Date S Ar A, B r_i:7•4
Refund Processed: Date -/j / - Bydhcf Invoice Processed: Date By
Permit Canceled: Date ,3 / - B Parcel T-:Added: Date By
I:\Building\>formsutzIp nitA.eeian,09 '14.doc
1111
N.
T I GARD
City of Tigard
March 3, 2016
Evergreen Gas
Atm: Marian Kahler
PO Box 388
West Linn, OR 97068
Re: Permit No. MEC2016-00051
Dear Applicant:
The City of Tigard has canceled the above referenced permit(s) and encloses a refund for the
following:
Site Address: 12415 SW 122' Ave
Project Name: Smith
Job No.: N/A
Refund Method: ® Check#220317 in the amount of$80.64.
❑ Credit card"return" receipt in the amount of$
Note: Please allow 2-5 days for this refund transaction to be
credited to your account by the company that issued your card.
❑ Trust account"deposit" receipt in the amount of$
Comment(s): Cancel permit per applicant's request as was a duplicate permit. Refund
80% of permit fees.
If you have any questions please contact me at 503.718.2430.
Sincerely,
Dianna Howse
Building Division Services Supervisor
Enc.
13125 SW Hall Blvd. • Tigard, Oregon 97223 • 503.639.4171
TTY Relay: 503.684.2772 • www.tigard-or.gov
: City of Tigard
TIGARD Accela Refund Request
This form is used for refund requests of land use, development engineering and building permit
application fees. Receipts, documentation and the Request forPermit Action form (if applicable) must
be attached to this request form. Refund requests are due to Accela System Administrator by
each Wednesday at 5:00 PM. Please allow up to 3 weeks for processing of refunds. Accounts
Payable will route refund checks to Accela System Administrator for distribution to applicant.
PAYABLE TO: Evergreen Gas DATE: 2/25/2016
PO Box 388
West Linn, OR 97068 REQUESTED BY: Dianna Howse
TRANSACTION INFORMATION:
Receipt#: 401615 Case#: MFC2016-00051
Date: 1/21/2016 Address/Parcel: 12415 SW 122nd Ave
Pay Method: CreditCard Project Name: Smith
EXPLANATION: Per applicant's request as customer cancelled job. Refund 80% of permit fees.
REFUND INFORMATION:
Fee Description From Receipt Revenue Account No. Refund
Example: Building Permit Fee Example: 2300000-43104 $Amount
Mechanical Permit 230-0000-43102 $72.00
12% State Surcharge 100-0000-24001 8.64
TOTAL REFUND: $80.64
APPROVALS: SIGNAT S/DATE:
TE:
1
If under$5,000 Professional Staff
If under$12,500 Division Manager
If under$25,500 Department Manager
If under$50,000 City Manager
If over$50,000 Local Contract Review Board
FOR TIDEMARK SYSTEM ADMINISTRATION USE ONLY
Case Refund Processed: Date: .,.�f,�//fo By:
L:\Building\Refunds\RefundRequest.doc N 09/01/2010